- Email: [email protected]
Anterior cruciate ligament reconstruction in patients over 50 years of age
The Knee 21 (2014) 1166–1168
Contents lists available at ScienceDirect
The Knee
Anterior cruciate ligament reconstruction in patients over 50 years of age David Figueroa ⁎, Francisco Figueroa, Rafael Calvo, Alex Vaisman, Gonzalo Espinoza, Federico Gili Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana — Universidad del Desarrollo, Santiago, Chile
a r t i c l e
i n f o
Article history: Received 12 April 2014 Received in revised form 23 July 2014 Accepted 6 August 2014 Keywords: Anterior cruciate ligament ACL 50 years Older patients ACL reconstruction
a b s t r a c t Purpose: To describe the clinical outcomes of patients over 50 years of age with following anterior cruciate ligament (ACL)reconstruction for acute rupture. Methods: A prospective series of patients over the age of 50 years with a diagnosis of ACL rupture who underwent ACL reconstruction was examined. Lysholm and International Knee Documenting Committee (IKDC) subjective scores were assessed preoperatively and at the final follow-up. All associated injuries were documented, and complications were reported. The patients' satisfaction and return to sports were documented. The statistical analyses were preformed with Student's t-tests for independent samples. Results: Fifty patients with a mean age of 52.12 years (50–64) and a mean follow-up period of 53.17 months (36–68) exhibited a mean postoperative Lysholm score of 93.7 (60–100) and IKDC score of 90.96 (57.5–100). Associated injuries occurred in 90% (45) of the patients and included the following: 76% (38) meniscal tears and 36% (18) osteochondral lesions. Complications occurred in 6% (3) of the patients and included the following: 4% (2) ACL re-ruptures and 2% (1) infections. Among all patients, 88% (44) returned to pre-injury sports levels, and 96% (48) were satisfied. Conclusions: For patients above the age of 50 years, ACL reconstruction appears to be a safe procedure with good to excellent results that are comparable to those for younger patients, and the possibility for returning to preinjury sports levels for these patients is high. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Anterior cruciate ligament (ACL) reconstruction is one of the most widely performed orthopaedic procedures, and its success rate in younger patients ranges from 85% to 95%.[1] Historically, older patients with ACL ruptures have been treated conservatively and urged to modify their physical activities.[2,3] Recent studies seem to demonstrate that conservative treatment is not associated with good results because such treatment might lead to increased risks of residual instability and associated injuries.[4,5] Moreover, patients must cope with their instability, and many go on to abandon highly demanding sport activities. Several studies have shown that, in middle-aged populations with ACL tears, selected and motivated patients can experience considerable recovery of function and stability after surgical reconstruction and predictably return to cutting and pivoting sports.[6–13] This growing body of evidence has broadly changed the approaches of surgeons toward the management of ACL-deficient knees in older patients. The purpose of this investigation was to describe the clinical outcomes of patients over 50 years of age with an acute ACL rupture who underwent ACL reconstruction and to document the associated injuries. ⁎ Corresponding author at: Clínica Alemana, Vitacura 5951, Santiago, Chile. Tel.: +56 222101011. E-mail address: franciscofi[email protected] (D. Figueroa).
http://dx.doi.org/10.1016/j.knee.2014.08.003 0968-0160/© 2014 Elsevier B.V. All rights reserved.
We hypothesised that active patients older than 50 years with reconstructed ACLs would have good to excellent functional results.
2. Material and methods This study examined a prospective, consecutive series of patients over 50 years of age with a clinical and imaging (magnetic resonance imaging [MRI]) diagnosis of an ACL rupture that was treated with ACL reconstruction from January 2007 to December 2010. The study was approved by the ethics committee of our institution, and all patients provided written informed consent to participate in this study. The surgical technique involved standard ACL reconstruction that was performed by the surgeons of our Knee Surgery Department. The procedure consisted of a transtibial ACL reconstruction using hamstring autografts or allografts when the diameters of the harvested tendons were small. All identified chondral lesions were treated with mechanic debridement and chondroplasty. All meniscal lesions were treated with partial menisectomies. The inclusion criteria were the following: patients over the age of 50 years who performed sporting activities regularly, with a clinical and MRI diagnosis of ACL rupture, and ACL ruptures of less than 3 months duration. The exclusion criteria were the following: patients younger than 50 years of age, multi-ligament knee injuries, ACL re-ruptures,
D. Figueroa et al. / The Knee 21 (2014) 1166–1168
inflammatory joint diseases, limb malalignment, and radiographic changes indicating Ahlbäck type IV to VI knee osteoarthritis.[14] All patients underwent preoperative physical therapy. The patients were discharged from hospital two days after surgery and followed in the outpatient clinic weekly until one month, monthly until six months and yearly thereafter. The initial rehabilitation protocol consisted of immediate postoperative rest and continuous passive mobilisation twice daily from the first postoperative day in addition to ambulation with two crutches, isometric quadriceps exercises, and manual patellar mobilisation. The steps of the rehabilitation are described in Table 1. Lysholm [15] and International Knee Documenting Committee [16] (IKDC) subjective scores were assessed before the surgery and at the final follow-up. The levels of sports activity were documented as Tegner activity scores pre-injury and at the final follow-up.[17] We also documented the presence of associated injuries in our series. The statistical analyses were preformed with Student's t-tests for independent samples.
1167
Table 2 Associated injuries. Lesion
N (%)
Meniscal injuries Medial Lateral Both Osteochondral lesions LFC MFC Patellar Multicompartimental
38 (76) 13 (26) 15 (30) 10 (20) 18 (36) 3 (6) 6 (12) 5 (10) 4 (8)
LFC: Lateral Femoral Condyle, MFC: Medial Femoral Condyle.
Forty-four patients (88%) returned to their pre-injury sports level. The mean Tegner score was 5.6 points (5–6) (p = 2.2136). Forty-eight patients (96%) were satisfied with their results.
4. Discussion 3. Results Fifty patients (50 knees) over the age of 50 years fulfilled the inclusion criteria and were enrolled in the study. Two patients (60 and 65 years old) refused surgery and preferred to undergo conservative treatment and stop their sports activities (these patients were symptomatic only during sports activities). All 50 patients who choose operative treatment exhibited symptomatic instability during physical activity, and 30 patients (60%) exhibited instability during daily activities. Thirty-three (66%) patients were male, and 17 (34%) patients were female. The mean age was 52.12 years (50–64). The mean follow-up period was 53.17 months (36–68). The types of graft used were hamstring autografts in 45 patients (90%) and allografts (Achilles tendon) in 5 patients (10%). The surgeries were performed at a mean time of 8.4 weeks (4–12) after the injuries. There were 45 patients (90%) with associated injuries (Table 2). Meniscal lesions were the most common and were present in 38 patients (76%). Isolated lateral meniscal tears were present in 15 patients (30%), isolated medial meniscal tears were present in 13 patients (26%) and combined meniscal tears were present in 10 patients (20%). Osteochondral defects were present in 18 patients (36%). The most common of these defects were isolated medial femoral condyle lesions in six patients (12%), patellar lesions in five patients (10%) and lateral femoral condyle lesions in three patients (6%). Four patients (8%) had multicompartment osteochondral lesions. There were three complications that each occurred in a different patient (6%). One (2%) patient experienced a postoperative infection that was treated with arthroscopic lavage and debridement and intravenous antibiotics, which resulted in the preservation of the reconstructed graft. Two (4%) patients experienced ACL re-rupture; one of these reruptures occurred at seven months and the other at nine months of follow-up. Both were treated with revision ACL reconstruction with an allograft (Achilles tendon). No patients were treated for postoperative arthrofibrosis or deep-vein thrombosis (DVT). In Table 3, we present the clinical scores of our series. The mean preoperative Lysholm Score was 50.1 points (30–65). The mean preoperative IKDC score was 42.9 (19.5–52.9). The mean preoperative Tegner score was 5.8 points. (5–6) The mean postoperative Lysholm score was 93.7 points (60–100). The mean IKDC score was 90.96 (57.5–100). Both of these scores were significantly better than the corresponding preoperative scores (p = 0.0007 and p = 0.0009, respectively). The largest gains among these scores occurred in the instability, swelling and physical activity items.
This clinical series demonstrated great improvements in the clinical scores (i.e., the Lysholm and IKDC scores) of patients over the age of 50 years with ACL ruptures who were treated with arthroscopic reconstruction. These findings refute the previous idea that similar groups of patients do not require surgical treatment.[3,4] These results are comparable to previously reported results regarding young and middleaged patients.[18,19] This series also demonstrated a high rate of returning to sports and patient satisfaction. In contrast, conservative treatment has a limited ability to achieve complete returns to preinjury sports activity levels particularly for sports that require pivoting activities.[4,5] In recent years, various studies focusing on ACL reconstructions in patients over the age of 40 years have been published [6–13] and have made arthroscopic reconstruction the preferred treatment for physically active patients in this group (presently, this includes nearly everybody in this age group); however, little has been published regarding patients older than 50 years [20–22], which makes the decision between surgical and non-surgical treatments more difficult for clinicians. Regardless, the few available studies have provided support for surgical treatment, which appears to have better clinical results particularly in more athletic older populations who cannot accept the residual instability and limitations related to the conservative treatment of ACL ruptures. The presence of significant osteoarthritis or limb malalignment might affect the results of ACL reconstruction. We excluded patients with signs of advanced osteoarthritis or clinical and radiologic malalignment from our series. Although the majority of our patients had concomitant preoperative meniscal or chondral injuries, the clinical
Table 1 Rehabilitation protocol after ACL reconstruction. Immediate POP
First day POP
First week POP
Third week POP
Fourth week POP
Second month POP
Sixth-eight month POP
Mobility Walking Therapy
0°–90° in PCM – –
0° to 100°–120° Assisted (2 crutches) Patellar mobilization Quadriceps isometrics
0°–120° Assisted (2 crutches) Free ROM Patellar mobilization TENS Cryotherapy
Complete Free –
–
–
–
Complete Free Free ROM Patellar mobilization Quadriceps strengthening TENS Cryotherapy Stationary bicycle Treadmill walk
Complete Free –
Gym
Complete Assisted (1 crutch) Free ROM Patellar mobilization Quadriceps strengthening TENS Cryotherapy –
–
Sports
–
–
–
–
Swimming
Stationary bicycle Treadmill walk Dumbbell work Swimming Soft jogging
POP: postoperatively; PCM: passive continuous motion; ROM: range of motion; TENS: transcutaneous electrical nerve stimulation.
Return to sports
1168
D. Figueroa et al. / The Knee 21 (2014) 1166–1168
Table 3 Lysholm, IKDC and Tegner scores.
Lysholm score IKDC score Tegner score
Preoperative
Postoperative
P value
50.1 42.9 5.8
93.7 90.9 5.6
0.0007 0.0009 2.2136
IKDC: International Knee Documenting Committee.
and functional outcomes were not affected, which indicates that initial osteoarthritis is not likely to be a contraindication for the reconstruction of a torn ACL. One reason for the hesitation to perform ACL reconstructions in older patients is the out-dated notion that this group would experience a greater number of complications than would younger patients. In our series, we observed a 4% re-rupture rate, and this rate is comparable to the published values than range from 0.7 to 10%.[23,24] Both of the patients who experienced re-ruptures were treated with revision ACL surgery and exhibited outcomes that were similar to those of the other patients at the final follow-up. We had one case of infection (2%), which resulted in an infection rate that is also comparable to the rates reported in the literature that range from 0.3 to 1.7%[25,26], although our rate falls in the upper part of this range. Based on these results, this procedure appears to be safe for this group of patients regardless of their older age, and the observed complication rate was comparable to that for younger patients. The limitation of this study is that, based on the positive results that have been reported in the literature, we offered surgical treatment to all patients with ACL ruptures who wanted to return to their previous sports activities regardless of age. Thus, during the period over which this study was conducted, only two of our patients declined to undergo ACL reconstruction. Thus, we lacked a control group to compare to our surgically treated patients. 5. Conclusion ACL reconstruction in patients over the age of 50 years appears to be a safe procedure with good to excellent results that are comparable to the results observed in younger patients, and the possibilities for this older group to return to pre-injury levels of sports activities are high. Conflicts of interest The authors declare that they have no conflicts of interest. References [1] Bach Jr BR, Aadalen KJ, Dennis MG, Carreira DS, Bojchuk J, Hayden JK, et al. Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar tendon allograft: minimum 2-year follow-up. Am J Sports Med 2005;33(2):284–92. [2] Ciccotti MG, Lombardo SJ, Nonweiler B, Pink M. Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up. J Bone Joint Surg Am 1994;76(9):1315–21.
[3] Jokl P, Kaplan N, Stovell P, Keggi K. Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. J Bone Joint Surg Am 1984; 66(5):741–4. [4] Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 2000;8(2):76–82. [5] Strehl A, Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma 2007;62(5):1159–62. [6] Legnani C, Terzaghi C, Borgo E, Ventura A. Management of anterior cruciate ligament rupture in patients aged 40 years and older. J Orthop Traumatol 2011;12:177–84. [7] Brown CA, McAdams TR, Harris AH, Maffulli N, Safran MR. ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies. Am J Sports Med 2013;41(9):2181–90. [8] Barrett G, Stokes D, White M. Anterior cruciate ligament reconstruction in patients older than 40 years: allograft versus autograft patellar tendon. Am J Sports Med 2005;33(10):1505–12. [9] Khan RM, Prasad V, Gangone R, Kinmont JC. Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2010;18(1):68–72. [10] Conteduca F, Caperna L, Ferretti A, Iorio R, Civitenga C, Ponzo A. Knee stability after anterior cruciate ligament reconstruction in patients older than forty years: comparison between different age groups. Int Orthop 2013;37(11):2265–9. [11] Seng K, Appleby D, Lubowitz JH. Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis. Arthrosc 2008;24(8):914–20. [12] Desai N, Björnsson H, Samuelsson K, Karlsson J, Forssblad M. Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register. Knee Surg Sports Traumatol Arthrosc 2014;22(2): 379–86. [13] Marquass B, Hepp P, Engel T, Düsing T, Lill H, Josten C. The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years. Arch Orthop Trauma Surg 2007;127(9):835–43. [14] Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh) 1968(Suppl. 277):7–72. [15] Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150–4. [16] Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1(3–4):226–34. [17] Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985;198:43–9. [18] Heier KA, Mack DR, Moseley JB, Paine R, Bocell JR. An analysis of anterior cruciate ligament reconstruction in middle-aged patients. Am J Sports Med 1997;25:527–32. [19] Brandsson S, Kartus J, Larsson J, Eriksson BI, Karlsson J. A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction. J Arthroplasty 2000;16:178–82. [20] Trojani C, Sané JC, Coste JS, Boileau P. Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older. Orthop Traumatol Surg Res 2009;95(1):22–7. [21] Dahm DL, Wulf CA, Dajani KA, Dobbs RE, Levy BA, Stuart MA. Reconstruction of the anterior cruciate ligament in patients over 50 years. J Bone Joint Surg Br 2008; 90(11):1446–50. [22] Ventura A, Legnani C, Terzaghi C, Borgo E. Single and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years. Arthrosc 2012;28(11): 1702–9. [23] Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg 1999;7:189–98. [24] Greis PE, Johnson DL, Fu FH. Revision anterior cruciate ligament surgery: causes of graft failure and technical considerations of revision surgery. Clin Sports Med 1993;12:839–52. [25] Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR. Descriptive epidemiology of the multi-center ACL revision study (MARS) cohort. Am J Sports Med 2010;38(10):1979–86. [26] Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2009; 17(9):1033–42.
Contents lists available at ScienceDirect
The Knee
Anterior cruciate ligament reconstruction in patients over 50 years of age David Figueroa ⁎, Francisco Figueroa, Rafael Calvo, Alex Vaisman, Gonzalo Espinoza, Federico Gili Knee Surgery Unit, Orthopaedics and Traumatology Department, Clínica Alemana — Universidad del Desarrollo, Santiago, Chile
a r t i c l e
i n f o
Article history: Received 12 April 2014 Received in revised form 23 July 2014 Accepted 6 August 2014 Keywords: Anterior cruciate ligament ACL 50 years Older patients ACL reconstruction
a b s t r a c t Purpose: To describe the clinical outcomes of patients over 50 years of age with following anterior cruciate ligament (ACL)reconstruction for acute rupture. Methods: A prospective series of patients over the age of 50 years with a diagnosis of ACL rupture who underwent ACL reconstruction was examined. Lysholm and International Knee Documenting Committee (IKDC) subjective scores were assessed preoperatively and at the final follow-up. All associated injuries were documented, and complications were reported. The patients' satisfaction and return to sports were documented. The statistical analyses were preformed with Student's t-tests for independent samples. Results: Fifty patients with a mean age of 52.12 years (50–64) and a mean follow-up period of 53.17 months (36–68) exhibited a mean postoperative Lysholm score of 93.7 (60–100) and IKDC score of 90.96 (57.5–100). Associated injuries occurred in 90% (45) of the patients and included the following: 76% (38) meniscal tears and 36% (18) osteochondral lesions. Complications occurred in 6% (3) of the patients and included the following: 4% (2) ACL re-ruptures and 2% (1) infections. Among all patients, 88% (44) returned to pre-injury sports levels, and 96% (48) were satisfied. Conclusions: For patients above the age of 50 years, ACL reconstruction appears to be a safe procedure with good to excellent results that are comparable to those for younger patients, and the possibility for returning to preinjury sports levels for these patients is high. © 2014 Elsevier B.V. All rights reserved.
1. Introduction Anterior cruciate ligament (ACL) reconstruction is one of the most widely performed orthopaedic procedures, and its success rate in younger patients ranges from 85% to 95%.[1] Historically, older patients with ACL ruptures have been treated conservatively and urged to modify their physical activities.[2,3] Recent studies seem to demonstrate that conservative treatment is not associated with good results because such treatment might lead to increased risks of residual instability and associated injuries.[4,5] Moreover, patients must cope with their instability, and many go on to abandon highly demanding sport activities. Several studies have shown that, in middle-aged populations with ACL tears, selected and motivated patients can experience considerable recovery of function and stability after surgical reconstruction and predictably return to cutting and pivoting sports.[6–13] This growing body of evidence has broadly changed the approaches of surgeons toward the management of ACL-deficient knees in older patients. The purpose of this investigation was to describe the clinical outcomes of patients over 50 years of age with an acute ACL rupture who underwent ACL reconstruction and to document the associated injuries. ⁎ Corresponding author at: Clínica Alemana, Vitacura 5951, Santiago, Chile. Tel.: +56 222101011. E-mail address: franciscofi[email protected] (D. Figueroa).
http://dx.doi.org/10.1016/j.knee.2014.08.003 0968-0160/© 2014 Elsevier B.V. All rights reserved.
We hypothesised that active patients older than 50 years with reconstructed ACLs would have good to excellent functional results.
2. Material and methods This study examined a prospective, consecutive series of patients over 50 years of age with a clinical and imaging (magnetic resonance imaging [MRI]) diagnosis of an ACL rupture that was treated with ACL reconstruction from January 2007 to December 2010. The study was approved by the ethics committee of our institution, and all patients provided written informed consent to participate in this study. The surgical technique involved standard ACL reconstruction that was performed by the surgeons of our Knee Surgery Department. The procedure consisted of a transtibial ACL reconstruction using hamstring autografts or allografts when the diameters of the harvested tendons were small. All identified chondral lesions were treated with mechanic debridement and chondroplasty. All meniscal lesions were treated with partial menisectomies. The inclusion criteria were the following: patients over the age of 50 years who performed sporting activities regularly, with a clinical and MRI diagnosis of ACL rupture, and ACL ruptures of less than 3 months duration. The exclusion criteria were the following: patients younger than 50 years of age, multi-ligament knee injuries, ACL re-ruptures,
D. Figueroa et al. / The Knee 21 (2014) 1166–1168
inflammatory joint diseases, limb malalignment, and radiographic changes indicating Ahlbäck type IV to VI knee osteoarthritis.[14] All patients underwent preoperative physical therapy. The patients were discharged from hospital two days after surgery and followed in the outpatient clinic weekly until one month, monthly until six months and yearly thereafter. The initial rehabilitation protocol consisted of immediate postoperative rest and continuous passive mobilisation twice daily from the first postoperative day in addition to ambulation with two crutches, isometric quadriceps exercises, and manual patellar mobilisation. The steps of the rehabilitation are described in Table 1. Lysholm [15] and International Knee Documenting Committee [16] (IKDC) subjective scores were assessed before the surgery and at the final follow-up. The levels of sports activity were documented as Tegner activity scores pre-injury and at the final follow-up.[17] We also documented the presence of associated injuries in our series. The statistical analyses were preformed with Student's t-tests for independent samples.
1167
Table 2 Associated injuries. Lesion
N (%)
Meniscal injuries Medial Lateral Both Osteochondral lesions LFC MFC Patellar Multicompartimental
38 (76) 13 (26) 15 (30) 10 (20) 18 (36) 3 (6) 6 (12) 5 (10) 4 (8)
LFC: Lateral Femoral Condyle, MFC: Medial Femoral Condyle.
Forty-four patients (88%) returned to their pre-injury sports level. The mean Tegner score was 5.6 points (5–6) (p = 2.2136). Forty-eight patients (96%) were satisfied with their results.
4. Discussion 3. Results Fifty patients (50 knees) over the age of 50 years fulfilled the inclusion criteria and were enrolled in the study. Two patients (60 and 65 years old) refused surgery and preferred to undergo conservative treatment and stop their sports activities (these patients were symptomatic only during sports activities). All 50 patients who choose operative treatment exhibited symptomatic instability during physical activity, and 30 patients (60%) exhibited instability during daily activities. Thirty-three (66%) patients were male, and 17 (34%) patients were female. The mean age was 52.12 years (50–64). The mean follow-up period was 53.17 months (36–68). The types of graft used were hamstring autografts in 45 patients (90%) and allografts (Achilles tendon) in 5 patients (10%). The surgeries were performed at a mean time of 8.4 weeks (4–12) after the injuries. There were 45 patients (90%) with associated injuries (Table 2). Meniscal lesions were the most common and were present in 38 patients (76%). Isolated lateral meniscal tears were present in 15 patients (30%), isolated medial meniscal tears were present in 13 patients (26%) and combined meniscal tears were present in 10 patients (20%). Osteochondral defects were present in 18 patients (36%). The most common of these defects were isolated medial femoral condyle lesions in six patients (12%), patellar lesions in five patients (10%) and lateral femoral condyle lesions in three patients (6%). Four patients (8%) had multicompartment osteochondral lesions. There were three complications that each occurred in a different patient (6%). One (2%) patient experienced a postoperative infection that was treated with arthroscopic lavage and debridement and intravenous antibiotics, which resulted in the preservation of the reconstructed graft. Two (4%) patients experienced ACL re-rupture; one of these reruptures occurred at seven months and the other at nine months of follow-up. Both were treated with revision ACL reconstruction with an allograft (Achilles tendon). No patients were treated for postoperative arthrofibrosis or deep-vein thrombosis (DVT). In Table 3, we present the clinical scores of our series. The mean preoperative Lysholm Score was 50.1 points (30–65). The mean preoperative IKDC score was 42.9 (19.5–52.9). The mean preoperative Tegner score was 5.8 points. (5–6) The mean postoperative Lysholm score was 93.7 points (60–100). The mean IKDC score was 90.96 (57.5–100). Both of these scores were significantly better than the corresponding preoperative scores (p = 0.0007 and p = 0.0009, respectively). The largest gains among these scores occurred in the instability, swelling and physical activity items.
This clinical series demonstrated great improvements in the clinical scores (i.e., the Lysholm and IKDC scores) of patients over the age of 50 years with ACL ruptures who were treated with arthroscopic reconstruction. These findings refute the previous idea that similar groups of patients do not require surgical treatment.[3,4] These results are comparable to previously reported results regarding young and middleaged patients.[18,19] This series also demonstrated a high rate of returning to sports and patient satisfaction. In contrast, conservative treatment has a limited ability to achieve complete returns to preinjury sports activity levels particularly for sports that require pivoting activities.[4,5] In recent years, various studies focusing on ACL reconstructions in patients over the age of 40 years have been published [6–13] and have made arthroscopic reconstruction the preferred treatment for physically active patients in this group (presently, this includes nearly everybody in this age group); however, little has been published regarding patients older than 50 years [20–22], which makes the decision between surgical and non-surgical treatments more difficult for clinicians. Regardless, the few available studies have provided support for surgical treatment, which appears to have better clinical results particularly in more athletic older populations who cannot accept the residual instability and limitations related to the conservative treatment of ACL ruptures. The presence of significant osteoarthritis or limb malalignment might affect the results of ACL reconstruction. We excluded patients with signs of advanced osteoarthritis or clinical and radiologic malalignment from our series. Although the majority of our patients had concomitant preoperative meniscal or chondral injuries, the clinical
Table 1 Rehabilitation protocol after ACL reconstruction. Immediate POP
First day POP
First week POP
Third week POP
Fourth week POP
Second month POP
Sixth-eight month POP
Mobility Walking Therapy
0°–90° in PCM – –
0° to 100°–120° Assisted (2 crutches) Patellar mobilization Quadriceps isometrics
0°–120° Assisted (2 crutches) Free ROM Patellar mobilization TENS Cryotherapy
Complete Free –
–
–
–
Complete Free Free ROM Patellar mobilization Quadriceps strengthening TENS Cryotherapy Stationary bicycle Treadmill walk
Complete Free –
Gym
Complete Assisted (1 crutch) Free ROM Patellar mobilization Quadriceps strengthening TENS Cryotherapy –
–
Sports
–
–
–
–
Swimming
Stationary bicycle Treadmill walk Dumbbell work Swimming Soft jogging
POP: postoperatively; PCM: passive continuous motion; ROM: range of motion; TENS: transcutaneous electrical nerve stimulation.
Return to sports
1168
D. Figueroa et al. / The Knee 21 (2014) 1166–1168
Table 3 Lysholm, IKDC and Tegner scores.
Lysholm score IKDC score Tegner score
Preoperative
Postoperative
P value
50.1 42.9 5.8
93.7 90.9 5.6
0.0007 0.0009 2.2136
IKDC: International Knee Documenting Committee.
and functional outcomes were not affected, which indicates that initial osteoarthritis is not likely to be a contraindication for the reconstruction of a torn ACL. One reason for the hesitation to perform ACL reconstructions in older patients is the out-dated notion that this group would experience a greater number of complications than would younger patients. In our series, we observed a 4% re-rupture rate, and this rate is comparable to the published values than range from 0.7 to 10%.[23,24] Both of the patients who experienced re-ruptures were treated with revision ACL surgery and exhibited outcomes that were similar to those of the other patients at the final follow-up. We had one case of infection (2%), which resulted in an infection rate that is also comparable to the rates reported in the literature that range from 0.3 to 1.7%[25,26], although our rate falls in the upper part of this range. Based on these results, this procedure appears to be safe for this group of patients regardless of their older age, and the observed complication rate was comparable to that for younger patients. The limitation of this study is that, based on the positive results that have been reported in the literature, we offered surgical treatment to all patients with ACL ruptures who wanted to return to their previous sports activities regardless of age. Thus, during the period over which this study was conducted, only two of our patients declined to undergo ACL reconstruction. Thus, we lacked a control group to compare to our surgically treated patients. 5. Conclusion ACL reconstruction in patients over the age of 50 years appears to be a safe procedure with good to excellent results that are comparable to the results observed in younger patients, and the possibilities for this older group to return to pre-injury levels of sports activities are high. Conflicts of interest The authors declare that they have no conflicts of interest. References [1] Bach Jr BR, Aadalen KJ, Dennis MG, Carreira DS, Bojchuk J, Hayden JK, et al. Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar tendon allograft: minimum 2-year follow-up. Am J Sports Med 2005;33(2):284–92. [2] Ciccotti MG, Lombardo SJ, Nonweiler B, Pink M. Non-operative treatment of ruptures of the anterior cruciate ligament in middle-aged patients. Results after long-term follow-up. J Bone Joint Surg Am 1994;76(9):1315–21.
[3] Jokl P, Kaplan N, Stovell P, Keggi K. Non-operative treatment of severe injuries to the medial and anterior cruciate ligaments of the knee. J Bone Joint Surg Am 1984; 66(5):741–4. [4] Fitzgerald GK, Axe MJ, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc 2000;8(2):76–82. [5] Strehl A, Eggli S. The value of conservative treatment in ruptures of the anterior cruciate ligament (ACL). J Trauma 2007;62(5):1159–62. [6] Legnani C, Terzaghi C, Borgo E, Ventura A. Management of anterior cruciate ligament rupture in patients aged 40 years and older. J Orthop Traumatol 2011;12:177–84. [7] Brown CA, McAdams TR, Harris AH, Maffulli N, Safran MR. ACL reconstruction in patients aged 40 years and older: a systematic review and introduction of a new methodology score for ACL studies. Am J Sports Med 2013;41(9):2181–90. [8] Barrett G, Stokes D, White M. Anterior cruciate ligament reconstruction in patients older than 40 years: allograft versus autograft patellar tendon. Am J Sports Med 2005;33(10):1505–12. [9] Khan RM, Prasad V, Gangone R, Kinmont JC. Anterior cruciate ligament reconstruction in patients over 40 years using hamstring autograft. Knee Surg Sports Traumatol Arthrosc 2010;18(1):68–72. [10] Conteduca F, Caperna L, Ferretti A, Iorio R, Civitenga C, Ponzo A. Knee stability after anterior cruciate ligament reconstruction in patients older than forty years: comparison between different age groups. Int Orthop 2013;37(11):2265–9. [11] Seng K, Appleby D, Lubowitz JH. Operative versus nonoperative treatment of anterior cruciate ligament rupture in patients aged 40 years or older: an expected-value decision analysis. Arthrosc 2008;24(8):914–20. [12] Desai N, Björnsson H, Samuelsson K, Karlsson J, Forssblad M. Outcomes after ACL reconstruction with focus on older patients: results from The Swedish National Anterior Cruciate Ligament Register. Knee Surg Sports Traumatol Arthrosc 2014;22(2): 379–86. [13] Marquass B, Hepp P, Engel T, Düsing T, Lill H, Josten C. The use of hamstrings in anterior cruciate ligament reconstruction in patients over 40 years. Arch Orthop Trauma Surg 2007;127(9):835–43. [14] Ahlbäck S. Osteoarthrosis of the knee. A radiographic investigation. Acta Radiol Diagn (Stockh) 1968(Suppl. 277):7–72. [15] Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982;10:150–4. [16] Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports Traumatol Arthrosc 1993;1(3–4):226–34. [17] Tegner Y, Lysholm J. Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 1985;198:43–9. [18] Heier KA, Mack DR, Moseley JB, Paine R, Bocell JR. An analysis of anterior cruciate ligament reconstruction in middle-aged patients. Am J Sports Med 1997;25:527–32. [19] Brandsson S, Kartus J, Larsson J, Eriksson BI, Karlsson J. A comparison of results in middle-aged and young patients after anterior cruciate ligament reconstruction. J Arthroplasty 2000;16:178–82. [20] Trojani C, Sané JC, Coste JS, Boileau P. Four-strand hamstring tendon autograft for ACL reconstruction in patients aged 50 years or older. Orthop Traumatol Surg Res 2009;95(1):22–7. [21] Dahm DL, Wulf CA, Dajani KA, Dobbs RE, Levy BA, Stuart MA. Reconstruction of the anterior cruciate ligament in patients over 50 years. J Bone Joint Surg Br 2008; 90(11):1446–50. [22] Ventura A, Legnani C, Terzaghi C, Borgo E. Single and double-bundle anterior cruciate ligament reconstruction in patients aged over 50 years. Arthrosc 2012;28(11): 1702–9. [23] Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg 1999;7:189–98. [24] Greis PE, Johnson DL, Fu FH. Revision anterior cruciate ligament surgery: causes of graft failure and technical considerations of revision surgery. Clin Sports Med 1993;12:839–52. [25] Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, Allen CR. Descriptive epidemiology of the multi-center ACL revision study (MARS) cohort. Am J Sports Med 2010;38(10):1979–86. [26] Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2009; 17(9):1033–42.